Dentist's Knowledge, Attitude and Practice towards Obstructive Sleep Apnea in Central India: A Questionnaire Based Survey

This work was carried out in collaboration among all authors. Authors MJA and JRG designed the study, wrote the protocol, and wrote the first draft of the manuscript. Author MNS managed the analyses of the study. Author SGD managed the literature search. All authors read and approved the final manuscript. Results: Overall dentists were observed to have good knowledge for domains of awareness, general findings and risk factors. Good knowledge was found in MDS for domains of screening and diagnosis (64.65% and 50.51%) and treatment and referral (65.66% and 57.58%) in comparison to the BDS group. Favorable attitude for all the domains was reported while poor practice in all domains. Conclusion: Dentists had favorable attitude towards OSA but poor knowledge in certain domains about OSA which may be linked to lacked clinical experience and hurdle in their practice. They were passionate about further education on OSA.


INTRODUCTION
One of the sleep-related breathing disorder is obstructive sleep apnea (OSA) which denotes repetitive incident of collapse of upper airway during sleep that can be partial or complete, proceeding to diminished (hypopnea) or absolute absence (apnea) of breathing for ten or more seconds and frequently related with either cortical arousal or a fall of saturated oxygen in blood [1,2]. Prevalence of OSA according to community-based studies from various portion of India have been estimated as 2.4% -4.9% in men and 1%-2% in women [3].
Overnight polysomnography (PSG) is a benchmark method of diagnosing OSA [8,9]. Various methods includes BANG questionnaire Body mass index, Age, Neck circumference, and Gender, STOP-BANG questionnaire Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender, STOP questionnaire for adults, Berlin, Epworth Sleepiness Scale and Apnea Risk Evaluation System (ARES). By this methods practitioners can directly screen the patients and can refer patients only with positive screening for PSG to obtain final diagnosis [2,10].
Currently the benchmark method for management of moderate to severe OSA is continuous positive airway pressure (CPAP). It is also an optional treatment for mild OSA [11][12][13][14]. Flemons et al found that deep palatal vault, enlarge tongue and Class 3 and 4 scores of uvula according to Mallampati classification are the features of high risk OSA patients [15]. Now Dentist's role is becoming gradually notable in evaluating, diagnosing, referring of OSA patients to another physician for assessing and assisting in the treatment [16].
Hence the purpose of the study was to evaluate the knowledge, attitude and practice about obstructive sleep apnea (OSA) among dentists including Bachelor of Dental Surgery (BDS) and Master of Dental Surgery (MDS) in Central India.

METHODOLOGY
This study was conducted from January 2021 to June 2021 for duration of 6 months at Nagpur in Central India.

Sample Size Calculation:
The sample size for the study was calculated from the formula and qualitative data of similar type of study conducted in India [2]. n = 4Pq / L 2 Where p= 68.9% dentists correctly responded the correlation between gender and OSA L = Allowable error = 10% of P = (10x68.9) / 100 = 6.89 q = 100 -P = 100 -68.9 = 31.1 n = (4 x 68.9 x 31.1) / 6.89 2 = 180.55 n = 185 subjects needed in the study Inclusion Criteria: The survey takes in a total of 185 dentists including BDS and MDS across Central India. Irrespective of gender, graduation year and curriculum graduated dentists were included in the study.
Exclusion Criteria: Undergraduates and Sleep physicians were eliminated from the study.

Data Collection:
In Google forms web based survey was specially created, spread to the dentists, and the replies were documented. This questionnaire survey included 23 questions. The questionnaire was put together by taking into consideration study carried out by Kale SS, [2]. Questionnaire was used to gather data on knowledge, attitude and practice of dentists toward OSA are compiled in Table 1. (Correct answers are mark bold).

a) Proclination of maxillary incisors b) Retroclination of maxillary incisors c) Proclination of mandibular incisors d) Retroclination of mandibular incisors 6
Who can prescribe oral appliances for OSA patients OSA is more common among?
Is snoring a symptom seen amongst OSA patient? a) Yes b) No c) Don't know 9 Does the prevalence of OSA increases with age? a) Yes b) No c) Don't know

Knowledge related questions Question Number
Question Answer

Risk factors 10
Factors which contribute to OSA are a) Obesity b) Hypertension c) Obesity and/or hypertension d) Don't know 11 Do you think abnormal maxilla and mandibular development can be a risk factor for OSA?
Enlarged adenoids are risk factors for OSA. a) Yes b) No c) Don't know Attitude related questions Screening and Diagnosis 13 Dentist plays a role in diagnosing and providing treatment for OSA.

a) Strongly agree b) Agree c) Neutral d) Disagree e) Strongly disagree 14
When dentist identifies bruxism habit in his patient it is his role to enquire about snoring and OSA. If the dentist encounters abnormal anatomical oral structures then he should further investigate for OSA and refer the patient to sleep physician. Would you be interested in attending course on dental management of sleep related oral diseases?

a) Yes b) No
Knowledge and practice questions were graded question wise as Good for ≥50% correct responses; poor for ≤ 50% correct responses, while attitude questions were graded as favorable for 50% dentists answering to agree and strongly agree; unfavorable for 50% dentists answering to neutral, disagree and strongly disagree.
Statistics: Data was analyzed descriptively and with inferential statistics using chisquare test and presented in the form of graphs and the analysis software used was SPSS 27.0 version with (P = 0.05) considered as level of significance.

RESULTS
Total 185 dentists completed and returned questionnaire. Of these 86 (46.49%) were BDS and 99 (53.51%) were MDS. The distribution of dentist's percentage based on the correct knowledge for each question was illustrated in

DISCUSSION
Out of the five domains in the knowledge related questions, for 2 domains including screening and diagnosis and treatment and referral, dentists have poor knowledge. As the dental syllabus does not include learning objective for OSA so this could be the cause for this and therefore the dentists have poor knowledge for the same.
Dentists including 88.37% of BDS and 100% of MDS were aware of OSA. Bian found that 75% of the GDPs were aware of OSA as a disease [17].
In general findings domain, OSA and gender predilection, 56.98% of BDS and 69.70% of MDS were acquainted about its correlation and this was in agreement with Jokubauskas et al. [12]. They found that around 68.9% dentists correctly responded the relation between gender and OSA. 43.02% of BDS and 30.3% of MDS were not aware of gender predilection of OSA; this was in agreement with Manohar et al. [11].
The results of the present study shows that among both BDS and MDS, knowledge for screening, diagnostic aids, risk factors such as obesity, proper treatment along with the correct time and condition for referral to the sleep physician; regarding their role in final diagnosis and about prescribing the oral appliances to OSA patients directly was insufficient. Similarly in a study wherein, about 60% of the dentists were not aware about the oral appliances to treat OSA and 21.15% could not identify different tests for diagnosing OSA [10].
Jokubauskas et al. [12] found that 78.8% dentists answered that they and medical practitioner can together deal with OSA similar findings found in Bian study [17]. The results of this study were also in accordance with the present study. About 41% dentist admit for their duty for suspecting OSA cases and 70.9% gave a positive view on participating in OSA treatment [14]. In this study favorable attitude of dentists for learning about OSA during graduation it is strongly suggested that the dental courses should include topics on OSA. This is in accordance with the study of Kale SS et al. [2].
In the present study, practices of the dentists towards domains directed towards screening, diagnosing and treating the OSA patients in their routine dental practice and continuing dental education was poor. Bian [17] found that 46% of the dentists after suspecting for OSA refer their patients to sleep physician while Manohar et al. [11] found that only 4% dentist correctly diagnosed the OSA patients. 85% dentist never consulted sleep physicians for the suspected OSA cases in their clinics and 89.8% dentists never fabricated any oral appliances for their OSA patients which is similar to the present study. In the present study, only 5.81% of BDS and 13.13% of MDS attended learning course regarding OSA management and 88.37% of BDS and 93.94% of MDS expressed their will to attend courses on OSA management. The results are consistent with Barnes et al. [18], wherein 90% of the dentists shows their interest in learning more about OSA while they are contrast with Jokubauskas et al. [12], who conveyed that 47.3% dentists attended continuing dental education courses for OSA learning.

CONCLUSION
OSA led to multiple health problems since it is a highly underdiagnosed condition. different specialties, among them includes dentists. In the present study dentists had favorable attitude towards OSA but poor knowledge in certain domains about OSA which may be linked to lacked clinical experience and hurdle in their practice. Thus dentists make a crucial contribution in the reduction of serious medical symptoms associated with OSA. Furthermore, there is a need to far improve the knowledge among the future dentist, by introducing overall knowledge of OSA in undergraduate and postgraduate dental education. In addition, dentists should direct themselves towards continuing dental education programs regarding OSA.

CONSENT
As per international standard or university standard, Participants' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
The ethical approval was acquired from Institutional Ethics Committee before beginning the study with ethical clearance number -SDKS/PG/STRG/Pros2.